President's Perspective

by Tom Baier, CAC/CCS

The Challenge Of Clinical Supervision. 

As a treatment program administrator, I have an abiding interest in the development of a workforce that can not just meet the needs of an increasingly complex, multi-problem client base but excel at it as well. This is no small task as the baby boomers approach retirement and students in college counseling programs seem to have little interest in entry-level positions in substance abuse treatment programs. Add to this our tendency to “burn out” our counseling staff and the future looks increasingly problematic for the provision of solid clinically-based treatment for those seeking addiction treatment services. As someone who continues to participate in numerous forums devoted to workforce development in addictions treatment on a regional, state and local level, it’s evident that the solutions are not readily forthcoming.

One focal area wherein there is general agreement that improvement is necessary is in the realm of clinical supervision. Clinicians who receive good clinical supervision report greater job satisfaction, less job-related stress and are able to separate their personal and professional lives. At the same time, the numbers of substance abuse counselors who have ever received regular and ongoing solid clinical supervision are few and far between. Most often, clinical supervisors are recruited from the counselor ranks and end up duplicating the kind of supervision they received. Clinical supervisors often end up little more than “note mommies” that monitor charts for documentation timeliness and other compliance issues. They end up as administrative supervisors rather than actual clinical supervisors as a review of their actual day-to-day activities readily reveals. Many are also burdened with their own caseloads as well due to fiscal considerations or workforce shortages. The problem is further exacerbated by the simple reality that, in a fee-for-service environment, clinical supervision is not a billable event. Finally, despite the importance of clinical supervision and the mandate for its provision by licensing and accrediting organizations, available training in this area is often difficult to find.  

So with all of these constraints, how is it possible to give and receive clinical supervision that is more than just lip service? Here are a few recommendations that are operational despite the systemic inhibitions: 

1. Ask for it. This should start at pre-employment. When you are interviewing for a clinical position, ask your interviewer what kind of clinical supervision is offered in the workplace. If the answer is fuzzy, so is the supervision. If you really want to be good at this you’ll learn that your own limitations are always being tested and that the best way to survive and flourish is to seek and obtain meaningful support, encouragement and learning. This learning, by the way, is often the process of learning about ourselves, as scary as that might be.
2. Use group supervision. Just as substance abuse clients seem to benefit most from the group process, treatment professional too have a lot to offer one another in a format devoted to group supervision. There are lots of methods for this that are primarily focused on the use of case presentation as a starting point for discussion. My favorite form of this method includes having counselors, on a rotating basis, present to their peer group their most problematic client, asking for recommendations for interventions or other insights into the particular case at hand.
3. Use Technology. Videotape is one of the most powerful (and intimidating) tools for supervision. I’ve only had a few rare occasions when a client refused to be videotaped (one was paranoid schizophrenic) but I’ve had many a counselor come up with a host of reasons why it wasn’t possible. Usually, they’ll start with saying that the clients won’t allow it. This is rarely the reality. If you’ve ever had good clinical supervision you know that it’s an intrusive process. This can be painfully intimidating if you’ve never been acclimated to close observation. All of your insecurities come roaring into play. A skilled supervisor knows how to gently introduce the counselor to what is a potentially ego-threatening procedure. Two methods I’ve used as a supervisor - videotape my own one-on-one supervision with the counselor with the focus on me and my methods for supervision. This adds a procedural norm, introduces the camera as a third-person observer and, at the same time is least threatening to the counselor. After all, the camera is focused on me, not them. Secondly, give the camera to the counselor and ask him to videotape a group during the course of the week; any group will do. Then, take the tape, review it for yourself, and pick two segments of the group session that you’d like to have a discussion about for our next supervision session. The counselor controls the process and the two segments can be viewed in either group or individual supervision for discussion and feedback.
4. Don’t be a “Chart Mommy.” Most of the administrative process associated with number of notes, timeliness of documentation, etc. should be designated as a clerical function. The supervisor’s focus should be that of quality rather than quantity. It’s not that the supervisor will not need to address poor time management issues related to chronically late documentation, she will. But the actual time-consuming review process for these elements are better left to clerical personnel who can generate a report for the supervisor’s review. This will become increasingly less problematic as more of us move toward electronic documentation wherein the computer will perform these mundane functions.
5. Don’t exist in a vacuum. This whole addiction treatment thing requires a clinical team. The “lone wolf” counselor who prefers to work alone, whose office door is always closed, who rarely, if ever, discusses his clients with his peers or supervisor, who becomes defensive when someone else wants to have some input with a client on his caseload, is a problem. More often than not, this is the counselor suffering from an imposter syndrome and is usually operating under the burden of his own insecurities. He doesn’t know it, but he needs supervision more than anyone else. Peer supervision can also be very valuable when it’s designed as a regular, ongoing process in an environment of mutual respect and trust. Finally, related to this topical area, is the need to stay current with the literature. I’m often amazed at how many counselors rarely read materials related to our field despite the reality that it is changing so rapidly. The Web offers us inexpensive and ready access to the most recent research on evidence based practices. If you’re not onboard with a regular and ongoing review of the literature, you’ll soon be left behind.

So there are a few briefly stated methods for integrating clinical supervision into our clinical practice. Ultimately, it’s all about having the ability to offer our clients the highest quality of care possible in an environment that supports measurable excellence while we, as clinicians, don’t just survive but thrive in the process.